MAUDE Adverse Event Report: COOK INC UNIVERSA FIRM URETERAL STENT SET; FAD STENT, URETERAL

Model Number	N/A
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Code Available (3191)
Date of Event	05/17/2016
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
(b)(4).The event is currently under investigation.
Event or Problem Description
Per the mw5063068, reported through the fda voluntary event reporting process, the manufacturer was informed that during a ureteroscopy procedure the stent broke.Another stent was available and used to complete the procedure.As of this date, patient outcome is unknown as information was not provided by reporter.
Additional Manufacturer Narrative
Blank fields on this form indicate the information is unknown or unavailable.(b)(4).Product has not been received and the investigation is ongoing.A follow-up report will be send on completion of the investigation.
Event or Problem Description
Per the mw5063068, reported through the fda voluntary event reporting process, the manufacturer was informed that during a ureteroscopy procedure the stent broke.Another stent was available and used to complete the procedure.As of this date, patient outcome is unknown as information was not provided by reporter.
Additional Manufacturer Narrative
Investigation - evaluation: a review of the complaint history, device history record, documentation, manufacturing instructions, specifications, and quality control of the device was conducted during the investigation.The device is shipped with an instruction for use (ifu) that describes the intended use, specific items are addressed such as: the complaint device was not returned therefore, no physical examinations could be performed; however, a document based investigation evaluation was performed.There is no evidence to suggest the product was not made to specifications.Review of device history record shows no nonconforming events which could contribute to this failure mode.Based on the information provided, no product returned and the results of our investigation, a definitive root cause could not be determined.We will continue to monitor for similar complaints.Per the quality engineering risk assessment no further action is required.
Event or Problem Description
Per the mw5063068, reported through the fda voluntary event reporting process, the manufacturer was informed that during a ureteroscopy procedure the stent broke.Another stent was available and used to complete the procedure.As of this date, patient outcome is unknown as information was not provided by reporter.

• Brand Name: UNIVERSA FIRM URETERAL STENT SET
• Common Device Name: FAD STENT, URETERAL
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 5872962
• Report Number: 1820334-2016-00793
• Device Sequence Number: 18836911
• Product Code: FAD
• UDI-Device Identifier: 10827002234052
• UDI-Public: (01)10827002234052(17)190325(10)6843414
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K961446
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 07/18/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: N/A
• Device Catalogue Number: UFH-624-RT1
• Was Device Available for Evaluation?: No
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 07/18/2016
• Supplement Date Received by Manufacturer: Not provided; Not provided; Not provided
• Initial Report FDA Received Date: 08/12/2016
• Supplement Report FDA Received Date: 11/10/2016; 01/11/2017; 12/23/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention